Building the bridge across the quality chasm.

Over the last four decades there has been an increasing emphasis on quality in health care. According to a series of recent US reports, however, there is no longer just a gap between what this quality is and what it could be, but a widening chasm (1). Crossing that chasm will be no simple task. It requires us to confront competing values that are at the heart of the major debates in public health. These include quality of services versus quantity of services, distributive justice versus excellence, and a framework for managing the perceived trade-offs between cost and quality. In the early years, the approach to quality in health care was summed up by the saying (famously used by a judge in a court case on pornography), ‘‘I won’t try to define it now but I know it when I see it’’. Definitions for technical aspects of quality have been formulated more recently, but these often fail to account for its important systems-level aspects, such as patientcentredness and equity (2). A much broader view is needed, which takes into account all the steps that lead to the delivery of high-quality health care services (3). This reality is painfully illustrated in the US health care system, where the promise of technically advanced care is limited by lack of insurance coverage for 40 million Americans, as well as marked disparities between racially, ethnically, socioeconomically and geographically defined groups (4). Even when financing is not an issue, for instance in the USMedicare programme for the aged, blind and disabled, or the UK’s National Health Service, fundamental shortfalls in quality and safety have been documented (5, 6). Financing, allocation of resources, workforce, and patient expectations all play a role in determining where particular systems are vulnerable to poor quality. One of the chief obstacles has been the lack of a coherent, comprehensive, and workable framework for systemic quality assurance. Three recent reports from the US Institute of Medicine (IOM) have focused on patient safety (7), the inability of the current system to provide quality care (1), and the preparation of a national report on health care quality (8). Between them, these could provide the beginnings of the framework we need. Common threads running through these reports (particularly their focus on the aims of safety, effectiveness, efficiency, patient-centredness, timeliness, and equity) can be translated into a plan to bring discipline to current and future efforts. This potential framework is complemented by a more explicit recognition of the trade-offs encountered in producing high-quality health care in the World health report 2000, on improving health system performance (9).Taken together, these reports and the emerging methodologies that underlie them hold some promise for a more systemic approach to quality, which includes quality measurement, data development, and research. These frameworks require complementary efforts to develop the tools needed for measuring, reporting, and improving quality systemically. The greatest progress has been in finding ways to measure quality by characteristics of health care providers and services that result in better outcomes for the patient, by using experiential ratings and clinical performance measures. But this kind of measurement, as well as the data infrastructure to support it, has so far been restricted to a few conditions such as heart disease and diabetes. This leaves major segments of the world’s population without quality measures that are relevant for ‘‘people like me’’ (10). Given the challenges in examining quality across national boundaries or in contexts other than those of industrialized countries, are we ready to take the big steps needed?We can learnmuch from recent and current work but it does not represent the kind of bold thinking that will be required. Nevertheless the stage has been set to promote bolder action. We have defined quality in a broad manner, and we know what a framework for it looks like. What we have to do now is build the bridge across the chasm between it and what we have so far achieved. n